Cystitis

WHAT IS CYSTITIS?

Cystitis is the infection of the urinary bladder. It is generally seen as a result of reproduction of an infection agent in the urine and infecting the bladder wall. It is the most common disease of the urinary tract. If it is not treated on time, infection may spread and cause pyelonephritis by effecting the kidneys. It may cause permanent damage on the kidneys.

HOW IS IT DIAGNOSED?

Patients with this disease have frequent urination (pollakiuria), burning sense (dysuria) and pain (strangury) while urinating, urgent desire to urinate (urgency), awakening for urination at nights (nocturia). Sometimes, pain occurs after the urination and several drops of blood may be seen. The urine may also be bloody (hematuria). Patients say in general that their urine is cloudy and smells bad. Also, many patients have painful sexual intercourse (dyspareunia) complaint. Abdominal sensitivity and even abdominal pain, nausea and vomiting may accompany to the symptoms in small children. FEVER is not PRESENT in general.

These clinical symptoms of the cystitis are almost typical and an experienced urologist considers the diagnosis of the cystitis from complaints of the patient.

These symptoms seen in cystitis may also be detected in non-bacterial cystitis, urinary bladder tumors, urinary bladder and ureter stones, inflammation of female external organs called vulvovaginitis and prostatitis and BPH (benign prostate hyperplasia) in men. Therefore, a careful DIFFERENTIAL DIAGNOSIS should be performed.

In general, urine and blood tests, ultrasonography and direct radiography are sufficient for the diagnosis. For chronic cases, radiographs obtained after intravenous drug administration (urography) or cytoscopic (observation of the urehtra and urinary bladder) may be performed in addition.

WHY CYSTITIS IS MORE IN WOMEN THAN MEN?

Urinary duct of women is quite shorter than men. The microbial agents, namely coli bacillus (Echericia Coli) are namely located in the perineum and reach to the urinary bladder via short urinary duct easily. Sexual intercourse contribute into the spread.

WHY SOME WOMEN HAVE CYSTITIS FREQUENTLY?

There are some risk factors for cystitis. Women who have these factors are inclined to have cystitis. Risk factors for cystitis are bad genital hygiene, genital pH over 4.5, vaginal infections, vaginal diaphragm for contraception, pregnancy, diabetes, constipation, wearing tight and synthetic underwear, menopause and postponing the urination.

METHODS OF PROTECTION FROM CYSTITIS

To be protected from cystitis or to rarefy cystitis attacks at least;

You should intake at least 1.5 to 2 liters of fluid. You send away the bacteria from your urinary bladder if they are or prevent their reproduction.

You should not postpone when you feel that you will urinate and you should clean your genital area from front to back.

If you are an individual who have cystitis frequently, you should not use bath tub, you should have shower.

You should wash your genital area before and after the sexual intercourse and urinate just after the intercourse.

You should make your vaginal cleaning with special shampoos of which the acidity was adjusted for genital region hygiene once a week.

You should wear cotton underwear and skirt instead of tight pants and synthetic underwear.

SHOULD YOU VISIT A DOCTOR FOR FINDINGS OF CYSTITIS?

If you have findings of the cystitis, you should immediately take protective precautions immediately. However, if no recovery is present in your complaints 24 hours after applying these precautions, you should contact a physician as early as possible because progression of the cystitis will have a risk to damage your kidneys and become chronic.

If you are pregnant, you should visit your physician as soon as possible.

Also, if you have blood in your urine, your urine is cloudy and odorous or high fever, pain on your waist and lower abdominal region, you should contact your doctor.

TREATMENT FOR CYSTITIS

Although antibiotics are not always necessary for the treatment of the cystitis, it is generally treated with antibiotics. If cystitis has repeated frequently or there is chronic cystitis, urine is obtained under clean conditions for urine culture and antibiogram and antibiotic is used until the bacteria reproduced in the culture and efficient antibiotic are detected; if the antibiotic used is inefficient as a result of the urine culture, it is replaced with an efficient antibiotic. Anti-cholinergic agents, hot sitting baths, urinary analgesic agents may be added into the treatment.

CHRONIC CYSTITIS

CHRONIC BACTERIAL CYSTITIS

It is an infection of the urinary bladder which repeats 3 or more times within a year and presents asymptomatic bacteriuria periods.

Tuberculosis cystitis, radiation cystitis and chronic prostatitis in men are important for the differential diagnosis.

Treatment should be performed with Antibiotherapy + urine acidification + long term suppressive antibiotic treatment with drugs including nitrofurantoin + TMP-SMZ in particular.

NON-BACTERIAL CYSTITIS

It defines the conditions where cystitis is presented clinically but bacteria is not reproduced in the culture.

Allergic cystitis

Infections with Gardnerella – Uroplasma – Candida or Herpes Simplex

radiation cystitis or chemical cystitis (cyclophosphamide)

INTERSTITIAL CYSTITIS (IC)

Interstitial cystitis is a non-bacterial inflammatory disease of the urinary bladder that the exact cause is unclear, has not a specific treatment, antibiotic treatment is insufficient and does not present any defect in urine tests.

There is not any diagnostic objective symptom, finding or examination method. The patients always complain about frequent urination, urgency, decrease on bladder capacity and bladder pain. Most of the physicians whom they refer with these complaints interpret the case as psychosomatic.

Altough the cause is unclear, it is accepted as an inflammatory response given by the bladder wall due to different factors. It is considered as a reaction created by the urine leaked in from the mucosa as a result of a damage on glycosaminoglycan (GAG) layer on the bladder mucosa. Factors include some allergic factors, mycoplasma infections, lactobacillus infections and some mechanical stimulus.

Patients with IC are divided into two groups recently.

Classical – ulcerative type (about 15% of all patients)

Non-ulcerative type

90% of the patients are women in general and prostatitis accompany to the symptoms in 10% of men.

To suspect from interstitial cystitis; no achievement has been obtained with standard diagnosis and treatment options in the patients with the following conditions;

Pelvic pain

Urgency

Frequent urination

Absence of infection in urine tests in general

Severe decrease on the bladder capacity

Reflection of the pain on perineum and rectum when bladder is filled

Bloody urination in some times

Pain sense in the vagina after urination

DIAGNOSIS

In general, to have a suspicion is the most important diagnosis stage!!!

Routine tests generally do not forward to the diagnosis. Most of the patients have many urine tests, urine cultures, urinary system ultrasonographies, tomographies and MRI tests which have been performed by different physicians and hospitals. None of them include a significant pathology.

A method that may be useful for the diagnosis is CYSTOSCOPY and BIOPSY even it is not efficient by 100%. Detection of Hunner Ulcer which may be seen even rare takes us to the diagnosis. To detect such ulcer is not essential. Likewise, mast cell increase should set us to think about the possibility even it is not specific by 100%.

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TREATMENT

It should be explained to the patients that the purpose is to decrease the symptoms and there is not any definite treatment yet!!!

The treatment is specific to the patient. There is not a single and efficient treatment methods for all patients. Options include fluid that will be administrated into the bladder, bladder dilatation, oral drugs, laser treatments, neuromodulation and open surgical methods as last resort.

Diet supports are very useful I addition to the medical treatment. The patients should avoid acidic foods and beverages, soar fruits and fruit juices, caffeinated drinks, spicy foods as much as possible.

The most popular oral therapies are “pentosan polysulphates (ELMIRON) and tricyclic antidepressants”. It is useful to use them together or separately for 6 months at least. The logic is to help repair and enlargement of the bladder layer.

The most popular drugs that will be administrated into the urinary bladder are “dimethylsulphoxide (DMSO), hyaluronic acid, chlorpactine and lidocain”. These may be applied with or without anesthesia within sessions. Likewise, it is useful to administrate them with ELECTROMOTIVE DRUG ADMINISTRATION PROCEDURES (EDMA) to increase the efficiency.

On the cases in which success couldn’t be reached with the procedures conducted so far for min. 6 months-12 months, “neuromodulation-bladder broadening sessions- laser treatments- surgical treatments (broadining or taking the bladder out) is applied.

CONSEQUENTLY, BOTH THE PATIENT AND THE PHYSICIAN SHOULD KNOW THAT THERE IS ALONG AND DIFFICULT WAY IN FRONT OF THE PATIENT WHO WAS DIAGNOSED WITH INTERSTITIAL CYSTITIS.!

RADIATION CYSTITIS

It may be seen during radiotherapy or even years after the therapy. Tissue integrity is disrupted due to the tissue ischemia and vessel damage occurred by the effect of the radiation and mucosa, the most inner layer of the urinary bladder peels off.

Patients have pollakuria – dysuria – hematuria, urgency and urgency incontinence due to decrease on the capacity and elasticity of the urinary bladder.

Final Diagnosis: Is put with cystoscopy.

Treatment: Is symptomatic (only to remove complaints). Urinary bladder is irrigated by administration of formalin or silver nitrate solutions into the urinary bladder for severe bleedings or cauterization is sufficient. Some surgical techniques or hyperbaric oxygen therapy may be used for treatment-resistant cases.

CHEMICAL CYSTITIS

The most significant example is the cystitis developed due to a chemotherapeutic (agents used for cancer treatment) called cyclophosphamide. The most important symptom is bleeding. Cyclophosphamide is not toxic to the urinary bladder itself and its metabolite in the liver, acrolein creates the problem.

Discontinuation of the agent and symptomatic treatment are applied for the treatment.